I de-escalate supervisor calls, managed end-to-end clinical care coordination, which included scheduling appointments with in-network providers and arranging in-home physical exams to help improve CMS Star Ratings and close HEDIS gaps.
A significant part of my day-to-day involved breaking down complex Medicare Advantage and Medicaid policies for members. I educated patients on their Part A, B, C and D benefits, explaining formulary tiers and the coverage gap, and I frequently handled coordination of benefits to determine primary versus secondary payers and prevent billing underpayments. I also consult providers and pharmacist to determine whether the service and prescriptions given is within the coverage. I also bring hands-on technical proficiency with industry-standard platforms like OptumRx, Cover-----------ds, and the UHC Provider portal.
